Original Paper
Received: February 18, 2002
Dig Surg 2003;20:115121
DOI: 10.1159/000069386
Implications of Removing a Normal
Appendix
C.L. Bijnen a W.T. van den Broek a A.B. Bijnen a P. de Ruiter a D.J. Gouma b
a Department of Surgery, Medical Center Alkmaar, and b Department of Surgery, Academic Medical Center,
Amsterdam, The Netherlands
Key Words
Appendectomy W Morbidity W Costs, appendectomy W
Diagnostic tools
Abstract
Background: The diagnosis of acute appendicitis re-
mains difficult, and therefore 1530% of the removed
appendices appear to be normal. The aim of this study is
to investigate the morbidity, mortality and costs of re-
moving a normal appendix in patients with suspected
appendicitis. Patients and Methods: A retrospective
study was performed on patients who underwent a neg-
ative appendectomy for suspected appendicitis in the
period 19911999 with a median follow-up of 4.4 years.
Patients who underwent an elective appendectomy or
appendectomy for other reasons were excluded. Re-
sults: In 285 patients (70% women, 30% men) a normal
appendix was removed. In 192 (67%) patients a muscle-
splitting incision was performed, in 6 (2%) a median lap-
arotomy, and in 51 (18%) the normal appendix was
removed by laparoscopy. In 36 patients (13%) a diagnos-
tic laparoscopy was converted to a muscle-splitting inci-
sion. Complications occurred in 16 (6%) patients, in 5
(2%) a reoperation was needed. The mean hospital stay
was 4.4 (SE 2.8) days, in case of complication 7.4 (SE 4.2)
days. The mean extra hospital costs of a negative appen-
dectomy were EUR 2,712. Conclusion: The removal of a
normal appendix has considerable complications and
2003 S. Karger AG, Basel
ABC 02534886/03/02020115$19.50/0
Fax + 41 61 306 12 34
E-Mail karger@karger.ch Accessible online at:
www.karger.com www.karger.com/dsu
Accepted: July 22, 2002
costs. In an attempt to prevent these costs, extra diag-
nostic tools should be considered. Expensive diagnostic
tools as diagnostic laparoscopy should be used selec-
tively in order to not further exceed costs.
Copyright 2003 S. Karger AG, Basel
Introduction
Appendectomy is the most commonly performed acute
abdominal operation because of the relatively high life-
time risk for men (8.6%) and women (6.7%) to develop
appendicitis [1]. The indication for operation is usually
based on a combination of clinical and laboratory find-
ings [24]. If a normal appearing appendix is found dur-
ing exploration, it is generally removed in order to avoid
future diagnostic confusion. As a result, 1530% of the
removed appendices do not have histological signs of
inflammation [57]. To improve the diagnostic accuracy
for appendicitis, diagnostic modalities such as ultrasound
(US), computed tomography (CT) scan and diagnostic
laparoscopy have been introduced. These tools though
have their own limitations, risks and costs. Sensitivity
rates for ultrasound vary between 75 and 90% and speci-
ficity rates between 84 and 100%, but the efficacy of ultra-
sound is observer-dependent and because of the relatively
low sensitivity rates, it is not useful in ruling out appendi-
citis [812]. Combining laboratory tests (C-reactive pro-
tein and white cell count) with US increased the diagnos-
A.B. Bijnen
Medisch Centrum Alkmaar, Department of Surgery
Wilhelminalaan 12
NL1815 JD Alkmaar (The Netherlands)
Tel. +31 72 548 24 12, Fax +31 72 548 21 71, E-Mail wtbroek@xs4all.nl
 Table 1. Other diagnoses obtained in patients from whom a normal appendix was removed: summarized for the 3
different age groups

n Age group (years) Treatment

014 1550 1 51

Mesenteric lymphadenitis 21 19 2 0
Fecalith 12 11 1 0
Meckels diverticle 1 0 1 0 resection diverticle
ovulation bleeding 5 1 4 0
Salpingitis 4 0 3 1 antibiotics
Ovarian cyst 5 1 4 0 ovariectomy (n = 3)
Torsion of adnex 3 0 3 0 adnex extirpation (n = 3)
Leiomyoma of uterus 3 0 3 0
Retrograde menstruation 1 0 1 0
Endometriosis 2 0 2 0
Adhesions 7 2 5 0
Diverticulitis cecum 3 0 3 0 perforation, cecum oversewn (n = 1)
Urinary tract infection 2 1 1 0 antibiotics
Gastroenteritis 1 1 0 0
Pneumococcal peritonitis 1 0 1 0 antibiotics
Crohns disease 1 0 1 0 conservative
Local infarction of omentum 1 0 1 0 local resection
Total 73 36 36 1

tic accuracy from 70.9 to 87.1% in a retrospective study of
2,351 patients [13]. The sensitivity of a CT scan is higher
(0.871), with a similar specificity rate of between 0.83
and 1, and is less observer-dependent [1418]. However,
CT scan is relatively expensive and exposes the patient,
often a fertile woman, to a relatively high radiation dose.
Laparoscopy is another reliable diagnostic tool for appen-
dicitis with the advantage of obtaining other (mostly
gynecological) diagnoses and the possibility of concomi-
tant therapeutic intervention. Reported negative appen-
dectomy rates for laparoscopic appendectomy are rela-
tively low: 413%, as a normal appendix can be safely left
in place [1925]. When open appendectomy is performed,
the preceding laparoscopy can be considered as an extra
diagnostic procedure with the accompanying risks of an
invasive procedure.
To determine the usefulness and the cost-efficiency of
these added investigations and to evaluate whether it is
justified to perform additional diagnostic procedures,
more should be known about the consequences of remov-
ing a normal appendix.
The aim of this study is therefore to investigate the
morbidity, mortality and costs (preoperative and inhospi-
tal) of removing a normal appendix in patients with sus-
pected appendicitis.
Patients and Methods
A retrospective chart analysis was performed of all patients who
underwent a negative appendectomy for suspected appendicitis in
the Medical Center Alkmaar in the period from 1991 to 1999. The
diagnosis normal appendix was confirmed by histopathological
investigation using serial cuts of the entire appendix, which was per-
formed routinely on all removed appendices. Patient records were
retrieved by searching the hospital administration database for all
performed appendectomies and the pathological database for histo-
logically normal appendices. Also patients who underwent appendec-
tomy for suspected appendicitis and who had been treated for anoth-
er possible cause of the right lower quadrant pain were included.
Patients who underwent an elective appendectomy or an appendec-
tomy for reasons other than suspected appendicitis were excluded.
The variables: age, gender, hospital stay, type of operation, other
obtained diagnoses, complications, reoperations and patients recov-
ery were noted and analyzed using the SPSS computer program. The
2 test was used when appropriate. A p value of ! 0.01 was considered
significant.
Costs were calculated by retrieving the costs in the year 2000 in
our community hospital for: routine laboratory investigation; ultra-
sound; CT scan; visit to the emergency ward; consultation of a sur-
geon; hospital admission; outpatient clinic visits; fee of the surgeon
in case of operation; anesthesiologists fee, and histopathological
investigation.

116 Dig Surg 2003;20:115121 Bijnen/van den Broek/Bijnen/de Ruiter/

Gouma
Table 2. Complications and treatment after
negative appendectomy in a group of Complication n Treatment
285 patients
Wound infection 5 reoperation: drainage of abscess (n = 2)
Incarceration of ileoinguinal nerve 1 reoperation: release of nerve
Ileus due to adhesion 1 reoperation: adhesiolysis
Postoperative ileus 2 nasogastric tube (n = 1)
reoperation: explorative laparotomy (n = 1)a
Urine retention 2 catheterization
Infiltrate RLQ 1 readmission, i.v. antibiotics
Postoperative hemorrhageb 1 administration of 6 packed cells
Hypertrophic scar 1 local excision
Awareness during anesthesia 1
Large hematoma 1
Total 16
Reoperation 5

RLQ = Right lower quadrant.

a Explorative laparotomy because of signs of peritonitis, during operation fecal impaction
was found.
b Child with idiopathic thrombocytopenia.

Results Table 3. The costs of the different diagnostic and treatment proce-
dures for patients who are referred to the emergency ward for sus-
pected appendicitis
Of the 1,821 patients operated for suspected appendi-
citis, a normal appendix was removed in 285 (16%) Cost, EUR
patients (200 women or 70%, and 85 men or 30%). The
mean age was 26 (SE 14) years. Visit emergency ward 29
Patients were divided into 3 groups: group 1 (children), Consultation surgeon or resident 14
Routine laboratory examination 14
age 014 years, n = 65, 24 males, 41 females; group 2
Ultrasound 63
(adults, including women of the childbearing age), age 15 CT scan 88
50 years, n = 208, 55 men, 153 women, and group 3 (elderly) Operation room costs diagnostic laparoscopy 267
age 150 years, n = 12, 6 men, 6 women. Most patients were Surgeon fee diagnostic laparoscopy 47
women in the age group 1550 years (p ! 0.01). Anesthesiologist fee diagnostic laparoscopy 30
One-day admission 469
In 192 (67%) patients a muscle-splitting incision was
Operation room costs appendectomy 363
performed, in 6 (2%) a median laparotomy, and in 51 Surgeon fee appendectomy 163
(18%) the appendix was removed by laparoscopy. In 36 Anesthesiologist fee appendectomy 54
patients (13%) a diagnostic laparoscopy was converted to Extra costs laparoscopic appendectomy
a muscle-splitting incision. Despite a preceding diagnostic 3 Endoloop EJ 10C 93
Endocatch 108
laparoscopy, a normal appendix was removed due to
Outpatient clinic control 44
doubt in the diagnosis, wrong diagnosis (misinterpreta- Histopathologic examination 24
tion), no other diagnosis found during laparoscopy, or no
visualization of the appendix.
In 73 (26%) patients, another diagnosis was obtained
that might have caused the right lower abdominal pain
and was treated if necessary (table 1). In group 1 more tion. Thus, a total of 276 unnecessary operations were
other diagnoses were obtained (36%) compared to groups performed.
2 (17%) and 3 (8%; p ! 0.01). The most common diag- Complications occurred in 16 (6%) patients during a
noses in children were mesenteric lymphadenitis and median follow-up period of 4.4 (SE 2.7) years (table 2). In
fecaliths. In 3% of the patients of groups 1 (n = 2) and 2 5 (2%) a reoperation was needed. All patients recovered
(n = 7), the underlying cause needed operative interven- well from these complications. The mortality was 0. The

Implications of Removing a Normal Dig Surg 2003;20:115121 117

Appendix
mean hospital stay was 4.4 (SE 2.8) days. This was longer
in case of a complication: 7.4 (SE 4.2) vs. 4.2 (SE 2.7) days
(p ! 0.01). There was no difference in hospital stay
between open appendectomy (4.4 days) and laparoscopic
appendectomy (4.3 days). The costs of the different diag-
nostic and therapeutic procedures in our hospital are
shown in table 3. Routine costs are EUR 57 for a patient
who visits the emergency ward for suspected appendicitis:
visit emergency ward (EUR 29); consultation surgeon or
resident (EUR 14), and routine laboratory examination
(EUR 14). An ultrasound will add EUR 63 to these costs,
a CT scan EUR 88, and a diagnostic laparoscopy with 2
days admission will add EUR 1,282. The hospital cost of a
negative appendectomy, including 4.4 days admission, a
routine control visit at the outpatient clinic, and histo-
pathological examination will be EUR 2,712 and in case
of laparoscopic appendectomy EUR 2,913.
Discussion
Removal of a normal appendix at operation for sus-
pected appendicitis could be considered an appendecto-
my en passant during a diagnostic procedure. In the
present study, the mean hospital stay of patients undergo-
ing a negative appendectomy was 4.4 days, and the com-
plication rate was 6%, as previously found (6.1%) by oth-
ers [26]. Also the reoperation rate is not negligible, namely
2%. These percentages are higher than in the case of diag-
nostic laparoscopy alone (mean hospital stay 2 days, com-
plication rate 0.3%, and reoperation rate 0%), as recorded
in a previous study [27]. Unfortunately, in 87 patients a
normal appendix was removed despite a preceding lapa-
roscopy. So in terms of mean hospital stay (2 vs. 4 days),
complications (0.3 vs. 6%) and reoperation rate (0 vs.
2%), a diagnostic laparoscopy is preferable over perform-
ing a negative appendectomy, but better judgement and
adequate management of the normal-looking non-in-
flamed appendix during laparoscopy are needed.
We calculated that the removal of a normal appendix
will cost EUR 2,712. According to the Dutch network and
national database for pathology (PALGA), 2,285 negative
appendectomies are performed yearly in the Netherlands.
Thus the negative appendectomies will cost the society
EUR 6,196,920/year. The economic loss due to sick leave
after hospital discharge is more difficult to calculate but
should be added to this amount. So there are at least two
important reasons for trying to lower the number of nega-
tive appendectomies, namely preventing complications
and reducing costs.
118 Dig Surg 2003;20:115121
One way to reduce the percentage of negative appen-
dectomies is to first observe all patients in whom the diag-
nosis is not clinically evident [28, 29]. This, however,
could lead to a delay in the diagnosis and treatment of
appendicitis. Another solution could be the use of extra
diagnostic tools. The cost-efficiency of the routine use of
such diagnostic procedures depends upon their sensitivi-
ty, specificity and costs. For example, if we aim for budget
neutrality and calculate EUR 2,712 as additional costs for
the removal of a normal appendix, a maximum of 2,712/
63 (43) ultrasounds, 2,712/88 (31) CT scans or 2,712/
1,282 (2) diagnostic laparoscopies could be used in order
to prevent one negative appendectomy.
These are of course theoretical estimates, as many oth-
er factors such as the potential consequences of a perfora-
tion due to delayed operation are not taken into account.
The illustrates, however, that especially if one uses diag-
nostic laparoscopy without removing the appendix lapa-
roscopically, the cost-efficiency could greatly increase by a
selective application to a subset of patients in whom the
diagnosis is not clinically evident.
Routine CT scan for patients with suspected appendi-
citis improved patient care and reduced the use of hospi-
tal resources and total costs in another study [30]. It
remains questionable, however, if it is justified to routine-
ly impose a large group of females in the childbearing age
to a considerable radiation dose.
The majority of negative appendectomies were per-
formed in women aged 1550 years. This reflects the dif-
ferential diagnostic difficulty in fertile females. For this
reason, others advise routinely performing a diagnostic
laparoscopy in women of the childbearing age with sus-
pected appendicitis, but in men its use is not recom-
mended [21, 31]. However, a considerable number of nor-
mal appendices were also removed in pre-menarche chil-
dren and men. Also in these latter subsets the diagnosis is
apparently not always obvious. The feasibility of identi-
fying such subsets, not based on gender, is demonstrated
in a separate study [32].
Others advocate removal of a normal-appearing ap-
pendix found in case of suspected appendicitis because at
histopathological examination the normal-appearing ap-
pendix might show increased cytokines, indicating an
inflammatory response [33]. Also neuroproliferation is
shown in the normal-appearing appendix and should be a
reason for removing it [34]. In a prospective study in
which a normal-appearing appendix found during diag-
nostic laparoscopy for suspected appendicitis was left in
place, recurrent abdominal pain was low both in the direct
postoperative period as in long-term follow-up, suggesting
Bijnen/van den Broek/Bijnen/de Ruiter/
Gouma
that it is safe to leave a normal appendix in place and that
the above-mentioned findings might not be of clinical
importance [32]. Furthermore, the morbidity and costs of
removing a normal appendix found in this study are rea-
sons not to remove a normal-appearing appendix.
Thus, we conclude that due to 6% morbidity and 2%
reoperation rates, removing a normal appendix is not a
harmless operation. Also, because a negative appendecto-
my is more expensive (EUR 2,712) than available diag-
nostic tools, these tools should be used to avoid negative
appendectomies. Ultrasonography should be the investi-
gation of first choice because it is relatively cheap and
noninvasive. If appendicitis cannot be confirmed at ultra-
sonography, the negative effects of the ionizing radiation
of the CT scan should be weighed against the negative
effects of diagnostic laparoscopy, which is relatively ex-
pensive, invasive and needs hospital admission. Expen-
sive and invasive diagnostic tools such as laparoscopy
should be used selectively and not as a routine.

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Implications of Removing a Normal Dig Surg 2003;20:115121 119

Appendix
 Invited Commentary
Moshe Schein
Bronx Lebanon Hospital Center, Bronx, N.Y.
The point of greatest tenderness is, in the average
adult, almost exactly 2 inches from the anterior iliac
spine, on a line drawn from this process through the
umbilicus Charles McBurney (18451913).
We are grateful to Dr. Bijnen and his colleagues from
the Netherlands for reminding us that removing a normal
appendix is associated with some morbidity and wastage
of financial resources. This of course is not surprising
because in surgery the more we do and the more inva-
sive what we do is, and the more unnecessary what we do
is the more complications we are going to generate.
In this series a normal appendix was found in 16% of
the patients. This conforms to the classical notion that a
negative appendectomy rate of 1520% is the norm [1].
Traditionally surgeons who achieved a lower rate of
white appendixes were blamed for being too conserva-
tive, risking a higher rate of perforations, and those with a
higher rate of negative appendectomies were accused of
being too aggressive. I should mention, however, that
when measuring the morbidity of negative appendecto-
mies only cases representing appendectomies performed
during truly non-therapeutic laparotomies/laparoscopies
should be included. By including a few cases of cecal di-
verticulitis and omental infarction the authors inflated
their series since the laparotomy in such instances was
indicated, necessary and therapeutic, with the potential
morbidity resulting from the necessary procedure rather
than from the incidental appendectomy.
The management of patients with suspected appendi-
citis has traditionally focused on the prevention of perfo-
ration by early operation, but at the expense of a high pro-
portion of unnecessary operations. But despite an in-
creased use of modern diagnostic modalities, the rate of
perforation has not declined [1, 2]. Population-based
studies document that diagnostic accuracy decreases as
the rate of appendectomy increases, but the rate of perfo-
ration does not change [2, 3]. This suggests that perfora-
tion is a different disease: patients come to hospital with
perforation they do not perforate while we investigate
them or observe them [2, 4].
While it is unlikely that we can modify the rate of per-
forated appendicitis, I believe that we can decrease the
number of unnecessary negative appendectomies. It has
been said that a fool with a tool is still a fool: indiscrimi-
nate and nonselective usage of modern diagnostic tech-
120 Dig Surg 2003;20:115121
nologies is only going to worsen the situation: in a study of
63,707 non-incidental appendectomy patients the propor-
tion of patients undergoing laparoscopic appendectomy
who were misdiagnosed was significantly higher than that
of open appendectomy patients (19.6 vs. 15.5%, p !
0.001) [1]. What is needed is common sense and rational
deployment of available diagnostic modalities. Frankly,
managing at least 1 case of adult (i.e. 113 years old) acute
appendicitis per week, I do not recall when I last removed
a normal one during a non-therapeutic laparotomy, or
missed an abnormal one. And this is how I do it:
1 Male patients with typical presentation. I do an open appendec-
tomy immediately or the next morning
2 Male patients with atypical presentation. I do serial re-examina-
tions if not better or still atypical, I do a CT
3 Females in the reproductive age with typical presentation. I al-
ways start with a transvaginal ultrasound (US) which frequently
detects ovarian pathology and fluid in the cul-de-sac to explain
the clinical picture. If US not contributory they are sent for a CT
4 Females with atypical presentation, see 2 and 3
5 As the above approaches differentiate between those who need an
operation and those who do not need one, I do not see any sense
in using laparoscopy as a pure diagnostic tool. Laparoscopy per
se represents a costly and invasive operation and despite asser-
tions that normal appendixes discovered during laparoscopy
should be left alone, many surgeons still feel uncomfortable with
this approach. Thus, commonly negative laparoscopy means
negative appendectomy. Instead, in my practice the lapscopes
sole objective is to better determine the correct incision in
patients with clinical peritonitis who need an operation, but do
not need a CT: is it appendicitis, perforated ulcer or sigmoid
diverticulitis?
This is what I do when all decisions are left to me, but
on my side of the Atlantic the diagnostic algorithm is
increasingly dictated by dogmatic emergency room per-
sonal who perform CT scans in lieu of clinical examina-
tion and plain abdominal X-rays. Such indiscriminate use
of CT scanning leads to a new syndrome which I call CT
appendicitis: you admit a patient with right lower quad-
rant pain and ambiguous clinical findings for observation.
Meanwhile the emergency room doctor orders a CT,
which is reported by the radiologist in the following morn-
ing. At this stage, the patient feels much better, his abdo-
men is benign, and he wants to go home but the radiolo-
gist claims that the appendix is grossly inflamed. Should
we treat the CT digital image or the patient?
Bijnen/van den Broek/Bijnen/de Ruiter/
Gouma
 As Dr. Bijnen and colleagues assert here, negative
appendectomy is not an innocuous procedure. By ap-
plying sound clinical judgment and selective usage of non-
invasive diagnostic procedures we can and should remove
less normal appendixes. Be it as it may, There are two
things in life that I will never understand: women and
acute appendicitis [5].
Implications of Removing a Normal
Appendix
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